TEACHERS and COACHES

ABOUT DIABETES

for the

TEACHERS and COACHES

of

Lindsey Swaithes

Lindsey is different than other diabetics you may know. She is on a regimen of Intensive Insulin Therapy and uses an Insulin Pump.

Please take the time to read this information. Therapeutic strategies for diabetes are changing rapidly and it is important that individuals supervising young people afflicted with diabetes be aware of the nature of the disease, the treatment as well as the problems that can occur on a daily basis. Some of the material covered is technical; however, I have tried to present it in a non-technical fashion. Much of the information presented is applicable to other children (and adults) with diabetes.

What is an Insulin Pump

An Insulin Pump is a miniaturized version of the device you see in hospital movies attached to a pole that meter bags of "liquid stuff" into the patient's I.V. An Insulin Pump contains a large syringe filled with insulin, a computer that allows the user to time and adjust the administration of insulin to their bodies, and a small motor to drive the syringe. Attached to the end of the syringe is a sterile tube (infusion line) fitted with a needle that is inserted into the soft tissue of the lower abdomen. The entire fluid system (needle, infusion line, and syringe) must be changed every few days to maintain a sterile environment and avoid infection at the infusion site on the abdomen.

Diabetes Explained

Lindsey suffers from Insulin Dependent Diabetes Mellitus (IDDM) also known as Type 1 Diabetes or Juvenile Diabetes. IDDM is an AUTOIMMUNE disease that destroys the cells in the pancreas that produce the hormone insulin which is required to metabolize glucose (blood sugar) and provide energy for cells in the body. People afflicted with IDDM produce no insulin whatsoever. Approximately one million people in the United States suffer from IDDM. Another 10 to 12 million people suffer from Type 2 (adult onset) diabetes where the pancreas fails to produce enough insulin. Type 2 diabetes is a 'different' disease with symptoms and complications that are similar to Type 1 diabetes. Type 2 diabetics can sometimes control their disease with diet alone or with the help of oral medications.

Short Term Problems Associated with Diabetes

HIGH BLOOD SUGAR

Without insulin the body cannot use glucose and shifts from metabolizing carbohydrate (glucose) to metabolizing fat for energy. This shift is accompanied by elevated blood sugar levels (hyperglycemia) and normal, acidic by-products of fat metabolism known as ketones. When fat is the main energy source, ketones accumulate and move the body's electrolyte balance into the acidic range, causing excessive urination and dehydration as the body tries to reestablish its acid balance by excreting the ketones. This life threatening condition is known as diabetic ketoacidosis (DKA). Total interruption of insulin to a person with IDDM can result in DKA within 4 to 8 hours. Regular blood sugar testing can detect elevated blood sugar levels and the onset of DKA and timely action can be taken to prevent problems from occurring.

LOW BLOOD SUGAR

Without an adequate supply of carbohydrates to support immediate metabolic requirements, a diabetic may experience low blood sugar (hypoglycemia). The symptoms of mild low blood sugar may include among other things; tremors, tingling, palpitations, sweating, anxiety, shivering, dizziness, confusion, headache, speech impairment, drowsiness, weakness, hunger, and blurred vision. Severe low blood sugar is associated with impaired cognitive function that results directly from brain glucose deprivation and may lead to unresponsiveness, coma, or seizure. The changes mentioned above may go unnoticed by a casual observer; however, the person experiencing low blood sugar can usually recognize and treat the symptoms without outside help. Because symptoms of low blood sugar can rapidly progress from moderate to severe if untreated, a person experiencing these symptoms should not be left alone until action is taken to raise blood sugar levels.

Known Long Term Problems Associated with Diabetes and Long Term Elevated Blood Sugar Levels

Diabetic Retinopathy

/ Deterioration and destruction of small blood vessels in the retina leading to loss of vision. The leading cause of blindness in the United States
Proteinuria and Nephropathy / Elevated levels of protein in the bloodstream damaging the kidneys and other organs. The leading cause of kidney failure in the United States.

Neuropathy

/ Damage to the nervous system resulting in the loss of sensation in the skin and extremities. Combined with the effects of peripheral vascular complications, the leading cause of amputations in the United States.
Cardiovascular and Peripheral Vascular Complications / Damage to capillaries, increased risk of stroke, ischemic heart death, and other microvascular complications.

Any or all of these complications may appear in as little as five years if blood sugar levels are not maintained at near normal levels.

Treatment of IDDM

For years, most diabetics have taken two and sometimes three injections a day of insulin to control their blood sugar levels and manage their diabetes. With this level of control it is almost impossible to maintain near normal blood sugar levels and the onset of long-term complications is inevitable. Since 1923 it has been recommended by diabetologists that blood sugar levels be maintained as close to normal as possible. It was not until 1993, however, that it was unequivocally demonstrated by the conclusion of the 10-year Diabetes Control and Complications Trial (DCCT) that intensive blood sugar management can dramatically reduce the risks and complications of diabetes. The trial consisted of 9000 patient years of observation of one group of patients on intensive insulin therapy and another group using the conventional 2 to 3 shots a day. The results of the trial demonstrated for the intensive therapy group a 76 percent reduction in the risk of development of retinopathy, a 54% reduction in incidence of nephropathy (kidney disease), a 60% reduction in incidence of neuropathy, a 34% reduction in the development of high cholesterol, and a 41% reduction in the risk for heart attack and stroke.

The intensive therapy group used two methods to control their blood sugar levels:

1)Multiple Daily Injections (MDI) consisting of three or more injections of insulin combined with regular testing of their blood glucose levels;

2)Continuous Subcutaneous Insulin Infusion (CSII or more simply - new technology in the form of an Insulin Pump) combined with regular blood glucose testing.

"Intensive Therapy" is just now emerging onto the clinical scene with the publishing in 1994 of the results from the DCCT.

Conventional insulin therapy practiced by most diabetics requires testing blood sugar 2 or three times a day and the periodic injection of a long and a short acting insulin. Meals and exercise must be carefully controlled and timed to match their body's insulin uptake and energy needs. The most noticeable element of this type of management is the periodic snacks required to maintain adequate blood sugar levels.

Insulin Pump users test their blood sugar 10 to 24 times a day and program their Insulin Pump to provide a continuous small drip of insulin that matches their body's background (fasting) insulin requirements (this is called the "Basal Rate"). In addition, pumpers program their pumps as needed to provide the exact amount of insulin to match the food they eat at the time that it is consumed (this is called a "Bolus"). The management effect of an Insulin Pump can be approximated by using MDI (multiple daily injections) and frequent blood sugar testing, however, MDI to achieve intensive therapy is much more rigorous and difficult to maintain (especially for a kid).

Normal Blood sugar levels for a non-diabetic fall in the 80 to 120 range. Glycosylated hemoglobin levels ( a measure of average blood sugar levels over a three month period) for a non-diabetic average around 5%. For a diabetic, consistently maintaining near normal blood sugar levels of 150 or below on a day-in day-out basis will produce a Glycosylated hemoglobin level of around 7% and a reduced incidence of complications as demonstrated by the DCCT. In the course of a day, a diabetic in "good control" may have blood sugar levels that swing from 50 to almost 300. The body's blood sugar servo-mechanism does not work and is replaced by machines; i.e., a Glucometer, Insulin Pump, and the brain of the patient to close the servo loop in real time. Blood sugar control for a diabetic is analogous to steering a car on a winding road from the back seat with two long rubber bands attached to the steering wheel while watching the road through the wrong end of a telescope.

What does this mean for you as a teacher or coach??? Now that you've read all about what can go wrong, what happens on a day to day basis? Usually everything works OK and Lindsey takes care of problems that develop. Diabetics need the people around them to simply be aware that they may suffer from low blood sugar and need assistance to correct a SEVERE low blood sugar or simply your patience and indulgence until they can correct a MILD low blood sugar. On the average, diabetics suffer a reaction which requires the assistance of others a couple of times a year or less. However, not to get complacent, moderate low blood sugars can and often do occur on a daily basis. Diabetics on intensive therapy on the average suffer 50% more low blood sugar reactions. Lindsey suffers 2 to 5 mild reactions a week which she has always caught and corrected herself. Someday this will not be the case and that is why the people around her must constantly be vigilant in the event that she needs your assistance.

Name: Lindsey Swaithes

DOB: 1/30/90

Address: 230 Tulane St

PARENTS: Pat and Mike Swaithes

HOME PHONE:972-278-2890

WORK PHONE:972-740-2728

Dr. Grace Tannin

Children’s Medical Center of Dallas

1935 Motor St

Dallas, TX 75235

214-456-5959

If Lindsey is in need of medical treatment it is IMPORTANT that the medical team be aware that she is an "Insulin Dependent Diabetic". It is common practice for emergency rooms to give patients fluids and glucose which is not necessarily a good idea for diabetics.

YOU NEED TO KNOW THIS / Lindsey can usually tell when she is LOW and will test and correct blood sugar levels as needed; however, if she appears moody or upset when there is no apparent good reason ASK IF SHE IS LOW AND ENCOURAGE HER TO TEST BLOOD SUGAR LEVELS. IF YOU SUSPECT LOW BLOOD SUGAR, DO NOT LEAVE HER BY ALONE OR ALLOW HER TO GO OFF ALONE WITHOUT ACCOMPANIMENT.

Physical exercise is not appropriate when Lindsey’s blood sugar levels are below 80 or above 150. She can correct a low blood sugar in 10 to 20 minutes using glucose tablets but should have food containing carbohydrate for long term correction. High blood sugars can be aggravated by exercise and may take several hours after an insulin infusion to return to acceptable levels. Likewise, Lindsey should not eat when her blood sugar levels exceed 160. Lindsey can usually correct high blood sugar levels in anticipation of a meal within an hour using an accelerated bolus. However, if She uses an accelerated bolus to lower blood sugar levels there is an increased risk for low blood sugar, she MUST eat within the appropriate time frame to avoid a subsequent severe low blood sugar level and insulin reaction.

EMERGENCY TREATMENT

In the event Lindsey experiences a severe insulin reaction (low blood sugar), she carries in her pack the following items.

Glucose tablets / 1 to 3 tablets taken orally if awake and cognizant
Glucose gel / in a tube or large foil packet. Administer entire contents if groggy or incoherent but breathing ok-- squeeze into mouth and rub on gums. Glucose enters the blood stream directly through the mucous membrane, it does not require digestion.
Glucagon Emergency Kit / In a small plastic box containing a syringe filled with sterile fluid and vial of dry powder. Squirt syringe into vial, shake vigorously, draw mixture into syringe, expel bubbles, then administer in muscle of butt or leg. DO NOT HESITATE TO ADMINISTER if unconscious and you suspect an insulin reaction. No permanent harm will result if you are wrong. In any event, call 911 and notify responding team that she is a diabetic then call parents.

Glucose and glucagon usually work within 10 to 15 minutes. Other forms of sugar are not suitable because they take much longer to enter the bloodstream since they must be broken down into glucose by the digestive system before the body can use them. A soda cracker or white bread is the next best thing to bring blood sugar levels up if glucose is not available. Simple starch is converted to glucose by the body within 30 minutes or less.

Sports and Exercise Physical activity increases the body's need for glucose and lowers blood glucose levels (as long as there is adequate insulin). Most ordinary exercise that is not strenuous or prolonged does not require any particular action on the part of the diabetic person. Prolonged physical activity such as marathon runs, or other activities that extend more than an hour, AND PARTICULARLY SWIMMING, require the intake of additional energy (glucose). Lindsey burns an extra 10 grams of carbohydrate an hour while swimming. You may see Lindsey munching on a cracker or other snack before or during exercise. This is normal.

Thank you for taking the time to read this and help Lindsey.

for Lindsey

Sincerely,

Pat & Mike Swaithes

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